=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164481305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ACHILLES E LITAO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2006
-----------------------------------------------------
Last Update Date | 02/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1029 S TRIMBLE RD
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-522-3341
-----------------------------------------------------
Fax | 419-522-1110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1029 S TRIMBLE RD
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-522-3341
-----------------------------------------------------
Fax | 419-522-1110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 35086572
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------